If you're receiving treatment or follow-up care for breast, gynecologic or any other type of cancer, thoughts of resuming sexual activity may be worrisome. And the thought of mentioning the subject to your doctor may be even worse. If your doctor or nurse doesn't bring up the topic, you may have to initiate a discussion on your own. Either way, knowing what to expect and how to adjust can help you overcome any hesitation you may feel.

Sexual problems experienced by women after cancer treatment include pain during intercourse, difficulty achieving orgasm, menopausal symptoms, infertility and poor body-image. Such problems often follow surgery, chemotherapy or radiation treatment. The good news is that many of them will improve.

Pain during vaginal intercourse is a common problem. It's most often caused by hormonal changes that lead to vaginal dryness.

"Painful intercourse can be related to a variety of factors, but it is often due to hormonal changes," says Julie Ponto, R.N., an oncology clinical nurse specialist at Mayo Clinic, Rochester, Minn. "Chemotherapy and hormonal therapy can cause vaginal dryness and vaginal atrophy, in which the shape and flexibility of the vagina are lost."

The reason hormone levels change after cancer treatment is that the treatment often involves damage to or surgical removal of the ovaries, preventing production of estrogen and progesterone. When the ovaries stop producing these hormones, menopause results. Symptoms of menopause include hot flashes, increased urinary tract and vaginal infections, and vaginal dryness and atrophy. Symptoms of menopause due to cancer treatment are often more abrupt and intense than are those of natural menopause.

"Premature menopause can be very dramatic and abrupt," says Ponto. "Most women go through menopause over several years, and their bodies gradually get used to the hormonal changes. The changes caused by premature menopause in women with cancer can be dramatically different. The abrupt decrease in estrogen and progesterone usually causes more intense symptoms."

For some women, hormone replacement therapy (HRT), estrogen cream or vaginal suppositories can help alleviate menopausal symptoms, particularly vaginal dryness. But not all effects of HRT are positive. Taking HRT as a combination therapy — estrogen plus progestin — can result in serious side effects and health risks. If your cancer is reactive to estrogen — as are some tumors of the breast or uterus, and possibly melanoma — your doctor probably won't prescribe estrogen replacement. An alternative solution for vaginal dryness may be a water-based lubricant.

"There are lots of over-the-counter creams, gels and other lubricants that vary in how they work and how they are applied," says Ponto. "You may need to experiment to find a product that you like."

A more severe problem than vaginal dryness is narrowing (stenosis). Radiation to the pelvis can damage the vaginal walls and their lining. Ulcers also can occur. The vaginal walls can scar or stick together, losing elasticity and narrowing the canal. Surgery to the vagina also can cause scars and adhesions to form.

To prevent such scarring and narrowing, doctors may recommend that you gradually stretch the vagina. One stretching method is penile-vaginal intercourse — about three times a week. If this is not an option, your doctor or nurse may suggest a vaginal dilator.

Vaginal dilators are latex, plastic or rubber cylinders that are made in a variety of sizes. These are lubricated and then inserted into the vagina and left in place for about 10 to 15 minutes at a time, three times a week or every other day. For severe narrowing, you may need a series of dilators of different sizes, which you work up slowly from the thinnest dilator — about the size of a small finger — to the thickest. Some doctors recommend that you begin using dilators three times a week during radiotherapy and continue for several years afterward. Even women who never plan on having intercourse can benefit from this therapy because it can help to make future vaginal examinations less painful.

In cases where cancer has arisen in or spread to the vagina, or in some cases of cervical cancer, the vagina itself may be surgically removed. A vagina may be rebuilt using skin grafts, sections of the intestine, or flaps of muscle and skin from the inner thighs. Such a vagina produces little or no natural lubrication during sexual arousal, so lubricants are needed.

According to the American Cancer Society, almost all women who could reach orgasm before cancer treatment continue to do so after treatment. Generally, unless cancer surgery involves removal of the clitoris or the lower vagina or damage to the spinal cord or pelvic nerves, a woman should still be able to achieve orgasm.

Foreplay, the steps you take to become sexually aroused, may require changes after cancer. For instance, if part of your foreplay was stroking sensitive areas that have since been affected by cancer treatment, you may need to find new areas that provoke sexual arousal when touched.

For both men and women, the breast represents a significant aspect of sexuality. Removal of the entire breast or changing its shape, look and feel with a lumpectomy can alter a woman's perception of herself as a sexual being.

"Some studies have shown that about one-fourth to one-third of women who have a breast cancer diagnosis experience some long-term sexual dysfunction," says Ponto. "This means years not months."

Author Leslie R. Schover, Ph.D., wrote in Sexuality and Fertility After Cancer, "Because breast cancer is the most common cancer in women, sexual problems have been linked to mastectomy more often than to any other cancer treatment."

The strongest predictor of sexual satisfaction after breast cancer is not the preservation of the breast. Rather, it's the state of a woman's psychological health and her satisfaction with her relationships before the cancer was diagnosed.

"If a relationship is stressful to begin with, then going through a cancer diagnosis is even harder on the relationship," says Ponto.

Some recommendations for increasing desire include reading a romantic book, watching a romantic or sexually explicit movie, or listening to music. Hand-held vibrators and other devices can lead to sexual arousal, stimulate increased blood flow to the genital area and help you reach orgasm.

Loss of fertility is a distinct possibility if you're undergoing cancer treatment. If you were planning to have children, this news can be devastating. Even women who have finished having children, or who choose not to, may feel some grief and loss if they become infertile as a result of cancer. Talk to your doctor or nurse if you're concerned.

One important consideration with regard to fertility and cancer is the use of birth control for women who remain sexually active during treatment. That's because both chemotherapy and radiation can cause severe birth defects. In general, women who have undergone cancer treatment should avoid pregnancy until one to three years after treatment has concluded. There is no evidence that a previous cancer history increases your risk of miscarriage or birth defects.

Many doctors include a discussion of sexual intimacy as a routine part of follow-up cancer care. When you meet with your doctor, he or she may discuss the following:

• Intimacy and sexuality issues relevant to you and your partner. Consider taking your partner with you to your doctor's appointment if you plan to discuss sexuality. Having your partner with you will ensure that both of you get the same information. If your partner is with you, better lines of communication may open.
• Intimacy and sexuality if you're single. If you're struggling with self-esteem and fear rejection, your doctor may refer you to a therapist or suggest that you join a support group to discover ways to feel more comfortable with dating.
• Resuming or continuing your sex life. Topics may include self-esteem and body image, such as clothing options to disguise a missing breast. Other topics are comfortable positions for vaginal intercourse, alternatives to breast caressing for arousal, and use of vaginal lubricants.

• Birth control and fertility concerns. Your doctor may recommend that you avoid becoming pregnant until after you're fully recovered from treatment and the risk of cancer recurrence is low. Your doctor can also refer you to fertility experts if you'd like to explore assisted reproductive technology.